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October 8th, 2010
12:17 PM ET

Mammograms: One doctor, her patients, herself

Monday:  Our journal club at the hospital reviewed the recent Norwegian trial showing limited benefits of mammograms.

Tuesday: I had my appointment for my own mammogram.

Wednesday: Veneta Masson’s article titled “Why I Don’t Get Mammograms” appeared in Health Affairs magazine.

There’s been a lot to think about in the realm of mammograms lately. As a primary care internist, I have to counsel patients on a daily basis about this screening test. As a faculty member of a medical school, I have to analyze the scientific data with my students. As a patient, I have to decide about my own medical care.

Ever since the U.S. Preventive Services Task Force changed their recommendations in 2009, I have changed my approach. I no longer press my patients to do a yearly mammogram, but talk about the pros and cons. For women who decline mammograms, I do not make them feel guilty. For women who choose them, we talk about options of every other year vs. every year. My mammogram talk has become more of discussion, more like the PSA discussion for prostate cancer screening.

In our journal club this week, we dissected the latest study from Norway. This study reviewed the histories of 40,000 women with breast cancer (Norway maintains a cancer database that is nearly 100 percent complete). They divided the cases up into geographical regions to include counties that offered biennial mammograms and counties that did not. They also divided the cases by time, cancers diagnosed before vs. after screening programs were initiated.

Over time, both the screened women and the unscreened women experienced a significant decrease in breast cancer mortality. Because this occurred even in women who lived in areas without screening programs, this decrease in mortality is attributed to better treatment.  Screening added a little more benefit, but it was small.

Crunching the numbers in this study, 2,500 women would need to do a mammogram to prevent one death from breast cancer. (For comparison 418 people would need to be screened for high cholesterol to prevent one death from heart disease).

2,500-for-one is not necessarily an unworkable number, but it is far from the panacea that the Breast Cancer Awareness Month would have you believe. Also not mentioned are the 10 women out of that 2,500 who will get an incorrect cancer diagnosis based on the mammogram, who will face unnecessary mastectomies, chemotherapy, and radiation.

At my own mammogram, one day after reviewing the nitty-gritty of this Norwegian study, I reflected on the mixed picture that the data offered. At least I could say I was well informed. After the procedure, the technician handed me an information flier along with pink-ribbon button.  I was uncomfortable with button, not because I don’t support patients with this awful disease, but because there was an implicit message that we are all required to be part of this advocacy group. I get concerned when there is a monolithic message out there, one that sidesteps critical nuances.

When I enter my hospital each day, I see a prominent poster featuring eight photogenic women, with one conspicuously absent. “One in eight women will get breast cancer,” the poster states, reminding women of their responsibility to get a mammogram.

But this poster is conveying misleading, even incorrect information. The oft-cited “one-in-eight” statistic is a lifetime risk. Women in their 30s have a one-in-233 chance of getting breast cancer. For women in their 40s it’s one-in-69. For women who live to 85, their risk is the true one-in-eight.

Implicit in the one-in-eight lifetime risk is that seven out of eight women will not get breast cancer. But nearly half of them will get atherosclerotic heart disease, which is the leading killer of men and women alike.

All of this is food for thought. I’ve decided that I will still get a mammogram for myself, though perhaps not every year. I’m cognizant of the limitations, and will try to counsel my patients accurately on the pros and cons. In the meanwhile, I highly recommend Veneta Masson’s essay about mammograms. It’s one of the most thoughtful, least ideological pieces out there.

Danielle Ofri is associate professor of medicine at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review. Her most recent book, “Medicine in Translation: Journeys with My Patients,” is about the care of immigrants and Americans in the U.S. health care system.


soundoff (24 Responses)
  1. Cindy Davis

    Mammographers are highly trained and educated in radiography, radiation physics, anatomic mammography positioning, and radiation safety. We love what we do and making a difference in our patients' lives by the care we share and by producing exceptional radiographs for our radiologists. I believe I can speak for most Mammographers that we'd much prefer to be called "technologists," as our time and professionalism in schooling and clinical expertise deserve this. Thank you.

    October 8, 2010 at 15:58 | Report abuse | Reply
    • Ituri

      You might not get many "thank you's" for your work, but know that there are people who value your expertise, regardless of the title they use to identify you. My mother is alive today because she insisted on getting a mammogram at 42, despite her doctor not wanting to bother with it because of her "low risk" categorization. She ended up having a rather vicious cancer, but it was caught early thanks to her screening. She's alive, healthy, and kicking today! Woo-hoo!

      October 8, 2010 at 16:15 | Report abuse |
    • Baby

      Sure!! you are the one developing the technology for what you get trainded to use. I am 100% certain you won't know the troubleshooting if the interument wasn't functioning well!!

      October 8, 2010 at 16:18 | Report abuse |
  2. Jennifer C

    I have to laugh. A lifetime risk of 1 in 8 is still too big of a risk! It's just like the statistics of having a child with Down Syndrome. There is a risk, no matter how small, and if mammograms, self breast examination, ultrasounds, doctor breast examinations help find breast cancer, then women need to employ ALL of these techniques!!! Who cares if a lump comes back benign? That news is WONDERFUL!!! Who cares if the insurance companies get upset about paying for that test that comes back benign? Do self breast examinations, get your mammograms starting at 40 and do it EVERY YEAR and don't let these new studies convince you otherwise. Mammograms hurt about as much as a tight squeeze. DO NOT BE AFRAID!!!!!

    October 8, 2010 at 16:28 | Report abuse | Reply
  3. lockwood5

    I am 31 years old, have never had a mammogram and never plan to get one...All this hype about women not wanting to get one, b/c they are uncomfortable or whatever... It's all moot now, b/c breast thermography has come along. If a doctor ever recommends that I have a mammogram (or when I turn 50 or so) I will go for breast thermography or perhaps even a newer technology at that point. Mammograms are obsolete, and I don't know why CNN has not picked up on that by now.

    October 8, 2010 at 16:55 | Report abuse | Reply
  4. Lindsey

    I can't say I will get regular mammograms or any at all. I have other health concerns that already demand my attention. I generally follow guidelines for screenings and preventative care, but this one's iffy. Everything is not beneficial to everyone.

    October 8, 2010 at 17:29 | Report abuse | Reply
  5. Margaret

    I went in for an annual mammogram, actually 3 month later than a year, and was told I had something that looked like a cyst, but didn't really look like breast cancer. No one seemed very concerned, but they decided to biopsy it. The pathology report said it was triple negative breast cancer, which tends to be more aggressive and has a higher recurrence rate. The nodule was very small, and they recommended lumpectomy and radiation. I was just blown away. Reading this article, I see that sometimes mistakes are made, and people are diagnosed with breast cancer who don't actually have it, and are treated with radiation, chemotherapy and mastectomy. I did not think that was possible.

    October 8, 2010 at 18:11 | Report abuse | Reply
  6. MikeR

    My wife just had a mammogram although she felt like skipping it this year. Guess what? It showed something suspicious that turned out to be an early stage but fast growing breast cancer. If she had left it for another year or waited until it was found by manual examination it would have been far worse. Ladies – Get those mammograms even though they are uncomfortable. The alternatives can be fatal.

    October 8, 2010 at 18:18 | Report abuse | Reply
  7. Margaret

    At the end of the day, I guess all you can effectively do to fight breast cancer is to go in for annual mammograms.

    October 8, 2010 at 18:33 | Report abuse | Reply
  8. Cieje Valentine

    As a raging hetero male, I must declare that I don't care what size they are as long as they are fully functional and HEALTHY! Ladies, please keep your scan appointments for your own sakes, if not for your families. Thank you.

    October 8, 2010 at 20:07 | Report abuse | Reply
  9. LS

    I study done on breast cancer survival in Norway is hardly applicable to the United States. First of all, Norway is extremely homogenous. They simply don't have the racial and ethnic diversity that we have in the US. Because genes play a large role in whether or not you get breast cancer and what type, the findings probably aren't very applicable to African-Americans, Native Americas or Asian-Americans. Or even people of Italian, Spanish or Greek Descent. In addition, Norway is a welfare state. They don't have to worry about health care coverage or how they will pay the bills if they can't work. (good unemployment + disability insurance). So if a problem is suspected, they can get a diagnosis and treatment, if needed, immediately. Plus their medical system is not nearly as convoluted as ours. Not to mention, they have different diet and exercise habits than the majority of Americans.

    Just some things to think about.

    October 8, 2010 at 23:40 | Report abuse | Reply
  10. LS

    Also, has anyone looked at the radiation caused my Mammograms?

    October 8, 2010 at 23:43 | Report abuse | Reply
  11. Strong Believer

    Being the daughter and sister of breast cancer victims, I strongly urge women not to take anyone's opinion that it doesn't look serious...My sister (at age 39) was diagnosed with an aggressive form of breast cancer less than one week after a mammogram showed nothing – tumor tissue has engulfed such a large portion of her breast (3 tumors comprised over 95% of her breast) that they were unable to differentiate between tumor and regular tissue. Thankfully, her surgeon after looking at the films, did a physical exam which made it quite obvious there was tumor involvement. A few days later in his office, he told her the plan was to buy her as much quality time as possible but her disease was terminal. She lived life to the fullest for the next 16 months, and then four weeks later after she said she was done fighting and had had enough, she gave up the fight and was at peace. Fast forward to 11 years later, when a minute (less than 1 cm.) tumor was discovered during Mom's routine mammogram – following a lumpectomy and mammosite radiation (concentrated – radioactive seed placed in cathether in breast twice a day for five days) – she was given a clean bill of health. Unfortunately, no one did a full body scan. Five months later, she too had lost her battle with this horrible disease and was finally at peace. It appears the breast cancer was a secondary location, and we will never know where her primary site (or type) of cancer began.

    While my first mammogram was at age 29, and has been done annually since that time, I still wonder if and when I will do battle with this disease. I have one sibling who doesn't have mammograms done at all – too expensive she says and one who is as structured or more about it than I am. Are mammograms really enough?? The bottom line is this – we must each become our own advocate for our physical well being. It is no one's responsibility but our own.

    October 9, 2010 at 18:07 | Report abuse | Reply
  12. Janine2

    I'd like to thank this doctor for voicing an opinion that differences from the blanket stream message that is constantly shouted at use. Younger women are more likely than older women to get a false positive or suspicious finding as our breast are denser.
    First I was called back for a second mammogram. Than I was told I needed a biopsy because I had calcification (more common in those under 40). I was told that this could mean DCIS which is stage 0 breast cancer very early stage very and treatable stage of breast cancer. Well I goggled it when I got home extremely upset. Turns out it’s not suppose to be REFERRED to as breast cancer as it’s not breast cancer as it’s not in the breast. Also, turns out that like prostate cancer it may live in a person body and never amount to anything. Yet many women are having mastectomies because they hear the word breast cancer a get scarred.
    I than had a biopsy which indicated it was not DCIS and it was benign. Was that the end of it no! They wanted me to have a lumpectomy. Why because there could still be cancer and that they could have missed. Remember it was benign yet surgery was recommended. Also mind you during this time I had five (5) mammograms, exposing me to radiation that can ironically enough cause cancer.
    I had declined the option of surgery. Before you start advising me that I was wrong, there’s more to my story. This is not my first false positive. I’ve had a false Ovarian and Thyroid cancer scare. The Ovarian one resulted in multiple sonogram and CAT scans which of course exposed me to radiation. The Thyroid one resulted in years of follow up MRI and MRI dyes, sonograms and biopsies. They have since reduced the levels at which they administering MRI because they discovered they were increasing peoples cancer rates. After years of Thyroid cancer testing I had to finally confront my doctor to get her to admit that I did not have Thyroid cancer and I was the unfortunate victim of over testing.
    I can trace my family back to the mid 1800 on both sides and no one has died from cancer of any type and no one was saved because of screening. With the exception of one who was exposed to high levels or second hand smoke, those who did get cancer all had a 2 pack a day habit for nearly 50 years. NO one had breast cancer.
    If your family has a history of cancer of any type be vigilant. I take my families stroke and heart disease risk seriously as this applies to me as an individual and not a static.
    We are testing everyone in the haystack as if we where all the same, we are not, we are individuals. Treat use as such medically.
    Please remember that MRI are a business now. They cost thousand of dollars each. And if they were not a money maker they wouldn’t be in your shopping plaza as they are in multiple locations near me.
    I may well turn out to be the first member of my family who gets cancer that is not related to smoking, do to all of the testing I’ve allowed my body to be exposed to, that previous generations of my family where never exposed to.

    Don’t forget that breast cancer rates have sharply decreased in the last decade. Why because the hormone treatments for menopause that was once widely prescribed, where found to cause cancer! We will never know how many women’s death where the result of standard practices during that period. Doctors and technicians, are human and don’t know everything.
    So remember your not a statistic you’re an individual you have to weigh the pluses and minuses for yourself. The younger you are the less likely you are to have breast cancers but the more likely you are to receive a false positive. However, if you do like statistic hears one for you 36, 171 Americans will die from the FLU this year. Almost as many as from breast cancer and most Americans will not get a flu shot. Yet you likely don’t have much to worry about, because if your young and health your risk factor is low. Not to mention you’re almost as likely to die in a car accident and yet we all get in our cars every day and don’t give it a second thought.

    And to those who’ve never been subjected to a false positive scare, be respectful and don’t brush it off.
    For those of us who have it’s a very traumatic experience.

    October 9, 2010 at 22:11 | Report abuse | Reply
  13. Margaret

    I think there is a lot of drama that surrounds breast cancer. Honestly, it is the only disease I know where you are considered a 'survivor' the moment you are diagnosed. I was getting really tired of being 'pinked' after my breast cancer diagnosis. More upsetting was the inquisition from other women: Did I smoke? (no) Did I drink too much? (no) Was I ever obese? (no) Did I have a history of breast cancer in my family? (no) Did I use oral contraceptives? (yes) Did I use HRT? (no). I understand that as we try to prevent breast cancer, we are looking to lifestyle as a factor, but we are getting dangerously close to blaming women for having breast cancer. I don't see this happening with men with prostrate cancer.

    October 10, 2010 at 09:27 | Report abuse | Reply
  14. Wendy

    AT LAST!!! Someone that perfectly reflects my belief about mammography (and pretty much every other one-size-fits-all medical recommendation) is a very rational way. I am printing this article and taking it to my doctor - it is very, very difficult to swim against the current when a doctor schedules maybe 5 minutes for discussion.

    Next on my list – routine colonoscopies. After driving a friend back from the hospital for this very invasive test, and listening to my doctor admonish me to hope that I'm not one of the 3% that may get it I've decided to pass on that one, too. The cost-benefit to me is just not there. Sorry.

    October 10, 2010 at 10:24 | Report abuse | Reply
  15. Catherine

    As a Sonographer at a women's imaging clinic, we find breast cancer on a weekly basis. We work hand-and-hand with the Mammographers to help better define a suspicious mass. If we find it early, years before you or your doctor can feel it, the treatment can be minimal and life-saving. If you wait years to get mammograms, or until you can physically feel the cancer, it may require extensive treatment or worse, be untreatable. 70% of breast cancers are are not hereditary; these women have no risk factors besides having breasts. Don't let one study erase years of progress in breast cancer detection. One mammogram a year is a very small price to pay to ensure a better and longer quality of life.

    October 11, 2010 at 06:45 | Report abuse | Reply
  16. Margaret

    I agree with you, Catherine, because this was my experience. My surgeon told me it would have been another 3-5 years before my breast cancer could be felt. He said my diagnosis was a testament to the power of mammography and sonography. Because my cancer was found so early, I had a lumpectomy, a sentinal node biopsy, and radiation, and avoided chemotherapy, mastectomy, and lymph node removal. None of the risk factors associated with breast cancer seemed to apply to any of the women I know who had breast cancer, and most were diagnosed in their 40s.

    October 11, 2010 at 07:49 | Report abuse | Reply
  17. Jason

    Interesting. Who would have thought less screening would not make a huge difference. http://www.arizonadentist.org

    November 15, 2010 at 23:35 | Report abuse | Reply
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